Niacin

Aka: Niacin, Nicotinic Acid, Simcor, Advicor, Cordaptive

1. Indications
   1. Low HDL Cholesterol
   2. Hypertriglyceridemia
   3. Combination therapy with Statin for Hyperlipidemia
2. Effects
   1. HDL increased (15-35%)
      1. No other agent raises HDL as much as Niacin
      2. However Niacin related HDL increase did not effect outcomes in 2011 AIM-HIGH study (prematurely stopped)
   2. Triglycerides decreased (20-50%)
   3. LDL Cholesterol decreased (10-25%)
      1. Significantly lowers LDL only at high dose
      2. Not a first-line agent for lowering LDL
3. Efficacy
   1. Does not affect all cause mortality
   2. May reduce Myocardial Infarction and coronary death risk
      1. Canner (1986) J Am Coll Cardiol, 8:1245
   3. However Statin with Niacin did not show benefit beyond Statin alone in AIM-HIGH study (2011)
4. Adverse effects
   1. Flushing
   2. Pruritus
   3. Skin irritation of neck and face
   4. Gastrointestinal upset
   5. Blurred vision
   6. Fatigue
   7. Glucose intollerance
   8. Hyperuricemia and gout
   9. Peptic Ulcer Disease exacerbation
   10. Hepatic toxicity with sustained release forms
5. Adverse Effects: Compliance and tolerance
   1. Poor Compliance: 40% discontinue use
   2. Reduced Flushing and Pruritus reaction
      1. Use Aspirin or Ibuprofen pretreatment
      2. Take dose with food
6. Contraindications
   1. Absolute
      1. Chronic Liver Disease
      2. Severe Peptic Ulcer Disease
   2. Relative
      1. Type II Diabetes Mellitus
      2. Severe gout
      3. Hyperuricemia
7. Preparations: Niacin
   1. Crystalline Niacin
      1. Dose: 1g PO tid ($5.50/mo) MAX: 6 g/day
      2. Example protocol (Use 500 mg tablets)
         1. Start: 250 mg at bedtime
         2. Titrate up over 6 weeks to 500 mg tid
      3. Pretreatment: Aspirin 81 mg before or Ibuprofen
   2. Niaspan (preferred)
      1. Safest of Niacins (only 4% GI side effects)
      2. More expensive than crystalline Niacin
      3. Example protocol for initiating doses
         1. One 500 mg tablet PO qhs for 1 month
         2. Two 500 mg tablets PO qhs for 1 month
         3. One 1000 mg tablet PO qhs for 1 month
         4. Check lFTs, Uric Acid, Glucose at 3 months
         5. Two 1000 mg tablets PO qhs
      4. References
         1. McBride (2003) New Therapeutics Lecture, Cable, WI
   3. Agents to avoid
      1. Avoid flush-free or no-flush Niacin
      2. Avoid Slow Niacin (Sustained Release)
         1. Decreased Safety due to hepatotoxicity
8. Preparations: Niacin combined with other agents
   1. Advicor: Niaspan (500-1000 mg) and Lovastatin (20-40 mg)
   2. Simcor: Niaspan (500-1000 mg) and Simvastatin (20 mg)
   3. Cordaptive: Niacin (extended release) with Laropiprant (to reduce Flushing)
9. Monitoring: Monitor while checking dose
   1. Glucose
   2. Liver transaminases
   3. Uric Acid
10. References
    1. Meyers (2003) Ann Intern Med 139:996-1002
    2. Last (2011) Am Fam Physician 84(5): 551-8
    3. Studer (2005) Arch Intern Med 165(7): 725-30
    4. Sharma (2009) Ann Intern Med 151(9):622-30